Developmental Dysplasia of the Hip and Ultrasound
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Developmental Dysplasia of the Hip and Ultrasound

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Clinical and ultrasound examination techniques in an overview

Clinical and ultrasound examination techniques in an overview

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Developmental Dysplasia of the Hip and Ultrasound Presentation Transcript

  • 1. Developmental Dysplasia of the Hip
  • 2. Overview Introduction Normal Development of the Hip Etiology and Pathoanatomy Epidemiology and Diagnosis Ultrasound morphologic and dynamic
  • 3. Introduction Developmental Dysplasia of the Hip • DDH - preferred term • Teratogenic hips • Subluxation • Dislocation-usually posterosuperior (reducible vs irreducible) • Dysplasia
  • 4. Background Risk Factors • 1/1,000 born with dislocated hip • 10/10,000 born with subluxation or dysplasia • 80% Female • First born children • Family history (6% one affected child, 12% one affected parent, 36% one child + one parent) • Oligohydramnios • Breech (sustained hamstring forces) • Native Americans (swaddling cultures) • Left 60% (left occiput ant), Right 20%, both 20% • Torticollis or LE deformity
  • 5. Breech Presentation
  • 6. Associated ConditionsTorticollis (15% have DDH) Metatarsus Adductus (1.5-10%have DDH)
  • 7. Normal Development Embryonic • 7th week - acetabulum and hip formed from same mesenchymal cells • 11th week - complete separation between the two • Prox fem ossific nucleus - 4-7 months
  • 8. Normal Hip Tight fit of head in acetabulum Transection of capsule • Still difficult to dislocate • Surface tension
  • 9. Pathoanatomy Ranges from mild dysplasia --> frank dislocation Bony changes • Shallow acetabulum • Typically on acetabular side • Femoral anteversion
  • 10. Pathoanatomy Soft tissue changes • Usually secondary to prolonged subluxation or dislocation Intraarticular • Labrum  Inverted + adherent to capsule (closed reduction with inverted labrum assoc with increased Avascular Necrosis) • Ligamentum teres  Hypertrophied + lengthened • Pulvinar  Fibrofatty tissue migrating into acetabulum
  • 11. Fatty Tissue (Pulvinar Thickens)
  • 12. Teres ligament (elongated and thickened)Docking the head
  • 13. subluxated dislocated Labrum: Cartilaginous acetabular lip. Neolimbus: a ridge of thickened articular cartilage
  • 14. Transverse ligament (hypertrophic)
  • 15. Hourglass shape of the capsuleby the iliopsoas tendon
  • 16. progressiveShortened of pelvifemoralmuscles
  • 17. Pathoanatomy Soft Tissue (Intraarticular) • Transverse acetabular ligament  Contracted • Limbus  Fibrous tissue formed from capsular tissue interposed between everted labrum and acetabular rim Extraarticular • Tight adductors (adductor longus) • Iliopsoas
  • 18. Tough Reductions… Obstacles to reduction • Extraarticular  Tight iliopsoas and adductors • Intraarticular  Labrum  Ligamentum teres  Transverse acetabular ligament  Pulvinar  Redundant capsule (hourglass)  +/- limbus
  • 19. Etiology and Epidemiology Multifactorial • Genetics and Syndromes  Ehler’s Danlos  Arthrogryposis  Larsen’s syndrome • Intrauterine environmental factors  Teratogens  Positioning (oligohydramnios) • Neurologic Disorders  Spina Bifida
  • 20. Diagnosis Newborn screening • Ortolani’s and Barlow’s maneuvers with a thorough history and physical • Warm, quiet environment with removal of diaper • Head to toe exam to detect any associated conditons (Torticollis, Ligamentous Laxity etc.) • Baseline Neuro and Spine Exam
  • 21. Diagnosis Key physical findings • Asymmetry  Limb length- Galeazzi  Abduction ROM  Skin folds  Limp  Waddilng gait / hyperlordosis - bilateral involvement
  • 22. Ortolani’s Maneuver* After 3 months of age tests become negative
  • 23. Barlow’s Maneuver
  • 24. CLINICAL PRESENTATION (THE NEONATE):Ortolani’s or Barlow’s sign Sonographic morphology.
  • 25. CLINICAL PRESENTATION (THE NEONATE):
  • 26. CLINICAL PRESENTATION(THE NEONATE): Barlow Ortolani clunk
  • 27. CLINICAL PRESENTATION (THE INFANT): Limited Abduction Galeazzi Sign Hips 90degrees
  • 28. CLINICAL PRESENTATION(THE INFANT):Asymmetric Folds
  • 29. CLINICAL PRESENTATION (THE INFANT):recognize a.bilateral dislocation Klisic Test Anterior superior iliac spine Greater trochanter Normal Dislocation
  • 30. CLINICAL PRESENTATION (THE WALKING CHILD):
  • 31. Femoral Neck Anteversion
  • 32. IMAGING STUDIES (ULTRASOUND) identify a silent hip
  • 33. IMAGING STUDIES(ULTRASOUND)
  • 34. IMAGING STUDIES (ULTRASOUND) BASELINE: line of ilium which intersects the bony and the cartilaginous portions of the acetabulum.15-29 As the femoral head subluxates: decreased ALPHA angle increased BETA angle
  • 35. IMAGING STUDIES (ULTRASOUND)The Ultrasound ( before 3 mo. ) Ilium Abductor M.
  • 36. IMAGING STUDIES (ULTRASOUND)
  • 37. Diagnosis Some cases still missed At risk groups should be further screened AAP • Recs further imaging (e.g. US) if exam is “inconclusive” AND  First degree relative + female  Breech  Positive provocative maneuver (Ortolani or Barlow) • Referral to Orthopaedist
  • 38. Imaging X-rays • Femoral head ossification center  4 -7 months Ultrasound • Operator dependent CT MRI Arthrograms • Open vs closed reduction
  • 39. Imaging Ultrasound • Introduced in 1978 for eval of DDH • Operator dependent • Useful in confirming subluxation, identifying dysplasia of cartilaginous acetabulum, documenting reducibility • Prox Femoral Ossification Center interferes • Requires a window in spica cast (avoid)
  • 40. UltrasoundFemoral headAbductorsIlium
  • 41. UltrasoundFemoral headAbductorsIlium
  • 42. UltrasoundFemoral headAbductorsIlium
  • 43. UltrasoundFemoral headAbductorsIlium
  • 44. UltrasoundGraf’s alphaangle
  • 45. UltrasoundGraf’s alphaangle>60° = normal*line w/ iliumbisects head 50/50
  • 46. Fig. 5-A:: Figs. 5-A, 5-B, and 5-C: Ultrasonography of the infant hip with use of thedynamic technique. (Figures kindly provided by Prof. H. T. Harcke.)Fig. 5-A: Photograph showing the position of the transducer used to obtain thetransverse flexion view. With the hip in this position of flexion and adduction, a posteriorpush is analogous to the Barlow test.
  • 47. Fig. 5-B:: A transverse flexion ultrasonographic view of a normal hip showsthe femoral head (F) remaining in contact with the ischium (arrows) duringmovement. A = anterior, L = lateral, and P = posterior.
  • 48. Fig. 5-C:: With instability and displacement, the femoral head moves laterallyand posteriorly. The laterally displaced head (F, open arrows) has no contactwith the ischium (solid arrows). Fibrofatty tissue (T) with increased echogenicityfills the acetabulum. A = anterior, L = lateral, and P = posterior.